29 March 2012 3:03 PM

Women have breast implants because they want to feel better about their appearance. As a man, I have no right to an opinion on this subject. However, as a former GP, I do have some observations.

My guess is that, as for cosmetic surgery of any kind and as for clothes and hairstyles, women judge themselves by what other women will think of their looks. Male opinions are a secondary consideration.

So, women may possibly have breast implants because of their own perceptions and personal values, rather than because of anything specifically to do with their breasts.

Some women have lopsided breasts or may be flat chested. Cosmetic surgery for them is a relatively straightforward consideration. The physical state is presumed to lead to a psychological state of distress.

Other women have had cancer, or other diseases of one or both breasts, and may understandably want to look as near as possible to what they were like before they had surgery. Again, the psychological considerations are relatively straightforward, as are the physical options.

It is only when implant operations are done for purely psychological reasons, in the absence of significant physical impairment that would be obvious to anyone other than the patient, that challenging ethical issues arise.

But should there be a problem even then? Maybe women should have a right to cosmetic surgery on demand. There are two difficulties with that attitude.

Firstly, body dysmorphia is the clinical condition in which women, commonly those with eating disorders, do not perceive their own form as other people see it. Some women become addicted to cosmetic surgery in their quest to find the perfect shape. They would probably benefit more from psychological treatment than surgical intervention.

Secondly, there is the issue of what surgical procedures should reasonably be provided from within the inevitably limited resources of the NHS. To provide every possible treatment for every possible physical and psychological condition would require more resources than the gross national product of our country. Rationing, in some form, is inevitable. It is also necessary so that those in greatest need of help are most likely to receive it.

This is where the financial and ethical dilemmas arise.

Let's start with an easy case. If a woman has cancer of the breast, it would normally be taken for granted that the State would pay for treatment. If an implant is inserted after her surgery, it would generally be thought reasonable for the State to pay for that. Maybe in extreme old age there could be a question on whether the potential risks of an implant were worth the benefits when a comfortable external prosthesis might be acceptable to the patient. Ageism is not a clear-cut concept.

But supposing the woman had paid for her cancer surgery and implant privately. If the implant then had to be replaced, would it be reasonable for her to have that done under the NHS, if she is entitled to it, or should she go back to the private surgeon?

Now consider the issue of an operation done for purely cosmetic reasons. If the initial operation was done in the NHS, after due consideration of psychological factors, then it would be reasonable to expect a faulty implant to be replaced under the NHS. If there is a long delay before hard-pressed NHS services are available and if there are dangers in not having the implant replaced, it would be reasonable for the procedure to be done privately and for the NHS to pay the bill.

But now look at the issue of an implant operation that was done in the private sector for purely cosmetic reasons. The woman herself would say that there was psychological justification. But an NHS psychologist might have said that the physical issue, and hence the psychological consideration, would not have been sufficient justification for surgery under the NHS.

Supposing this woman had spent all her savings on the original implant and now had no money to pay for the more complex surgery involved in the removal of a faulty implant and replacement by a new one. Should that procedure be done under the NHS if the woman is entitled to NHS care? Or should the private surgeon and hospital foot the bill?

Would the situation be any different if the patient is wealthy but still entitled to NHS care?

This brings up the whole issue of the relationship between the state and private sectors in health care.

These considerations are thorny at the best of times. In the present circumstance, it is likely that everyone will have an opinion and nobody will listen to any other,

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28 March 2012 7:36 PM

Patients are generally very understanding when doctors, and other healthcare professionals, make mistakes and immediately acknowledge them and apologise for them. But the medical indemnity associations, who insure doctors and others against malpractice claims, tend to go ballistic.

It is very difficult for them to defend a professional who has already admitted his or her guilt. Where financial compensation is at stake, the sums involved can be very considerable.

The NHS Litigation Authority’s report shows that it recorded 12,142 claims against NHS trusts in 2010-11. Of these, the uniquely talented mathematicians of this authoritative body say that 8,655 were clinical claims, up from 6,652 the previous year, and 4,346 were non-clinical, up from 4,074.

A further 22,364 claims were still open at the end of the financial year.

The authority – funded partly by trusts and partly by the Department of Health directly – paid out £729m under its main clinical scheme and a further £134m under claims relating to incidents that took place before 1995.

The government is understandably concerned, financially as well as clinically, that there should be such haemorrhage.

Some of it can be attributed to ambulance-chasing lawyers, who encourage people to make claims. They may offer legal help on a 'no win, no fee' basis. But if the accidents didn't happen in the first place, and if the judgement went against the claimant, the NHS would have less to worry about.

As it is, the prospect of settling over 22,000 claims this year will distress the Chancellor no end.

We know that the risk of dying through medical error is three times the risk of dying in road accidents. Doctors are three times as dangerous as cars and lorries. Placing ourselves in the hands of doctors, even before illness itself is taken into account, is therefore three times as dangerous as using the roads.

Doctors cannot shelter behind the insurance companies, other than in financial terms, when observing this carnage.

Nor can The General Medical Council correct errors of this magnitude simply by waving thick sticks.

Nor can The Care Quality Commission have any significant effect by insisting upon polices and procedures.

Those of us who do clinical work have to be aware that we are all fallible. This is not always disastrous. But what counts, up at the sharp end of clinical practice, is our ability to recognise our human failings and try to correct them as best we can. Failure to do so means that everyone is damaged: our patients, our colleagues, staff and employing institutions and also ourselves.

Doctors have to admit that we are human. I myself now work as a counsellor, rather than as a doctor, but that change of habitat does not cure me of professional grandiosity.

As with my former colleagues, I was trained by other doctors. We are a self-perpetuating oligarchy.

We need to remind ourselves that we are not Gods. We are not an M.D.eity.

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27 March 2012 12:14 PM

My friend Iwan does not recognise his wife. That is a tragedy for both of them. Alzheimer's disease has destroyed their life together. If only something could have been done earlier. This is now the hope of the Prime Minister for new sufferers.

Iwan and I went through school, the army and medical school together. He was supremely fit and joined the SAS, eventually being their doctor. He could not have kept himself in better shape, physically and mentally. But fate, probably through his genetic inheritance, dealt him a terrible blow. His mind has died. While I sit blogging, he just sits. I weep for my longest friend and for his family.

Mr Cameron says that he wants 'an all-out fight-back against dementia'. It seems an odd phrase for him to use because, until now, dementia always wins in the end.

But we thought that about HIV. Yet nowadays many sufferers live active lives for twenty years after the date of diagnosis. How wonderful it would be if, after further research, earlier diagnosis and more effective treatment, we can say the same for Alzheimer's disease.

Already one quarter of all hospital beds are occupied by patients suffering from dementia. As the population lives longer, that figure will rise. This is a clinical and financial problem of epidemic proportions.

Research funding will now more than double, to £66 million a year, by the year 2015. All patients over 75, admitted to hospital for any emergency, will be screened for dementia. Screening will also take place in the community, as part of the regular NHS check-up for people between the ages of 40 and 74.

The hope is that earlier diagnosis will lead to more effective treatment and richer quality of life for longer.

I remember the time when Iwan and I were in medical school together. Many cancers were then untreatable. Nowadays the frontier has been pushed back. Many cancers are now treatable, giving either extended comfortable and functional life, or they are even totally curable.

That must be the hope for future sufferers from Alzheimer's disease, perhaps the most frightening of all chronic illnesses.

My father's mind failed three years before his body packed up. He had an undignified and disturbing end to his bright, creative life. I don't want that to happen to me. Or to anyone else.

Living Death

My friend Iwan does not recognise his wife. That is a tragedy for both of them. Alzheimer's disease has destroyed their life together. If only something could have been done earlier. This is now the hope of the Prime Minister for new sufferers.

Iwan and I went through school, the army and medical school together. He was supremely fit and joined the SAS, eventually being their doctor. He could not have kept himself in better shape, physically and mentally. But fate, probably through his genetic inheritance, dealt him a terrible blow. His mind has died. While I sit blogging, he just sits. I weep for my longest friend and for his family.

Mr Cameron says that he wants 'an all-out fight-back against dementia'. It seems an odd phrase for him to use because, until now, dementia always wins in the end.

But we thought that about HIV. Yet nowadays many sufferers live active lives for twenty years after the date of diagnosis. How wonderful it would be if, after further research, earlier diagnosis and more effective treatment, we can say the same for Alzheimer's disease.

Already one quarter of all hospital beds are occupied by patients suffering from dementia. As the population lives longer, that figure will rise. This is a clinical and financial problem of epidemic proportions.

Research funding will now more than double, to £66 million a year, by the year 2015. All patients over 75, admitted to hospital for any emergency, will be screened for dementia. Screening will also take place in the community, as part of the regular NHS check-up for people between the ages of 40 and 74.

The hope is that earlier diagnosis will lead to more effective treatment and richer quality of life for longer.

I remember the time when Iwan and I were in medical school together. Many cancers were then untreatable. Nowadays the frontier has been pushed back. Many cancers are now treatable, giving either extended comfortable and functional life, or they are even totally curable.

That must be the hope for future sufferers from Alzheimer's disease, perhaps the most frightening of all chronic illnesses.

My father's mind failed three years before his body packed up. He had an undignified and disturbing end to his bright, creative life. I don't want that to happen to me. Or to anyone else.

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25 March 2012 9:10 PM

Californian researchers say that they are close to 'the holy grail' of heart medicine. They have devised an inexpensive test to give up to three weeks advance warning of a heart attack.

When a crack occurs in the wall of a coronary artery, as it can do, for example, from the effects of high blood pressure or cigarette smoking, lining cells are released into the blood stream. These cells will be detectable in a blood sample before a blood clot forms in the artery.

The test is a long way from being perfected. It needs to be able to differentiate cells being released through any other cause. Also it needs to discern whether they were there already.

Even so, it is exciting to consider the prospect of using a simple test to enable preventive action to be taken.

I can foresee two pitfalls. There are some anxious patients who might want to have the test every three weeks for the rest of their lives. The researchers hope to counter that fear by developing implantable chips that enable constant monitoring in appropriate patients with high risk of heart attacks. That will help patients who have clear clinical risk but it might increase cardiac neurosis in those who do not.

My other concern is that people will become increasingly absorbed with physical aspects of health so that they overlook everything else. There is a lot more to health and happiness than merely the absence of disease. Life should be fun.

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23 March 2012 1:36 PM

A recent survey from The Office for National Statistics shows that the number of people getting married in England and Wales in 2010 increased by 3.7% since the year before. My new love and I thought we should do our bit for England for this year.

We're getting married in the morning, just the two of us with two witnesses. Actually, the truth is that we got married yesterday afternoon but we like the song. It has a wonderful sense of life.

We didn't want any hurrah. This was our personal special day.

We're the marrying type. My first marriage lasted 48 years until my wife died. The first marriage of my new love lasted 35 years until her husband died. We didn't need to get married but we chose to do so. It's a statement of commitment.

We are both in full time work. I'm not sure what the tax implications of marriage are for us. I don't care. My relationship with my new wife is more important to me than anything else.

Pat is two years younger than me. I admit that I've run off with a popsie. She will be a child bride. Lucky me to have found anyone at all, let alone someone so vital.

She's American, which means that I shall be able to get a Green Card, enabling me to work in the USA. Now that's what I call a result, but it wasn't my sole motive in marrying her.

We got married because we believe in the institution of marriage. We want everyone, including ourselves, to know that we are totally committed to each other.

We are not partners. We are mad and passionate lovers. We want no euphemisms. We want the real thing.

The prospect of having children does not excite us. I suppose that nowadays almost anything medical is possible. But we don't think it would be fair to young children to have parents old enough to be their grandparents or even great grandparents.

Anyway, we have a lot more living to do for ourselves. It's our time now. We are doing all the things we could not afford the time or the money to do when we were younger. We're having a great time. Our life is so carefree, it occasionally feels like one opera or concert or play or film or restaurant or holiday after another. Again, we are doing our patriotic duty. We are spending what we earn and contributing to the national economy.

But there is nothing that we want to leave to the State when we die. We don't want to contribute to a wealth tax or an inheritance tax. Hopefully, we'll have given away our possessions long before then to whoever we ourselves choose.

We don't take our health for granted but, barring the effect of genetic inheritance and the result of unfortunate events, good health is largely self-generated by doing things that are beneficial and avoiding doing things that are harmful. We're in good shape.

We like the idea of eventually living in a South Kensington hotel, rather than in a nursing home in the countryside. We believe we would get more personal care and have a more exciting social life. That's an investment worth investigating.

But hopefully that's a long way off. We look forward to a mutually supportive, secure and happy relationship together for many active years. That's the pledge we gave to each other when we said 'I do'.

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21 March 2012 2:50 PM

I bought a house and set up a business. Maybe I got it all wrong. Perhaps I should have lived a completely different life.

Nowadays I have no mortgage, loans or debts of any kind. It's such a relief to be free of the burdens of ownership.

Never since my twenties have I felt so free. I had completely forgotten what it's like to have no concerns over possessions or property.

The budget will have virtually no effect on me. I pay my rent and insurance, my Council tax, utility bills and phone bills and also my income tax but nothing else. I have no other bills. Great.

I have no responsibility for staff. I no longer employ any. Wonderful.

I am not inspected by functionaries or controlled by jobsworths. Bliss.

I have no car. That saves me a bit of money and lots of grief.

I have no garden. I have no need of one when the London parks are so beautiful.

Above all, my time is my own. I have minimal forms to fill in, no policies and procedures to write or administrative outcomes to monitor. I can do with my time whatever I personally choose to do with it. My life is mine. Wow!

Why did it take me so long to discover the personal benefits of social and commercial isolation?

Perhaps in my childhood I should have been taught to take, rather than to produce.

Maybe at university I should have banged the drums of protest, rather than work for professional qualifications and contribute to the musical life of my college.

Then, on entering the real world, it might have been a good idea to avoid marriage and children and work for someone else, or for the State, rather than for myself.

As it is, I reflect upon the privileges of responsibility for others and I wonder if they were worth the costs.

Did our children benefit from what my wife and I gave them, socially, educationally and financially? Or would they have done better by learning to fend for themselves?

Did all of our patients benefit from what we supplied them? Or would some have done better by learning to be more independent?

Did we ourselves benefit from the hours that we worked and the risks that we took? Or would we have done better to earn a basic living and leave the creation of new ideas and enterprises to others?

Looking now at the world created by present-day Statists, what should we advise the next generation? To work or shirk? To be entrepreneurs or eco warriors?

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19 March 2012 8:34 AM

On just one day last week, we were told that one soft drink a day raises the risk of a heart attack, that two rashers of bacon a day raises the risk of heart disease and cancer by 20%, and that eating the recommended five portions of fruit and vegetables each day results in dental decay.

I can't wait for tomorrow's epistle! That's what this outpouring really is: a religious tract or a political treatise. Our lives are being taken over by health fascists.

They say that this information is for our own good but their true motive is that we should respect, and even worship, them while they take progressively more control of our physical lives.

They may say that they want to protect the resources of the NHS but they forget that people who live longer cost more to care for.

I don't take fizzy drinks and I don't eat sugar. I rarely eat red meat. I obey my dental hygienist dutifully when she commands me to floss. I do all that by choice.

I don't drink alcohol or smoke cigarettes or use drugs. I don't use caffeine - tea, coffee or chocolate - in any form. Again, these are my personal choices, although they were forced upon me by my addictive nature.

But I do drink a lot of milk and eat a lot of butter and cheese.

I don't care what the health fascists say. I absolutely refuse to do something, or not, purely because they tell me that it is good for me.

I prefer to forget all their strictures while I'm doing the work I love and taking advantage of all that London has to offer. Rewarding work and stimulating music, theatre or film are what are really good for me because they get me out of myself, expand my emotional life and human insight, and give me sheer unadulterated pleasure.

Now let me turn the tables on the health fascists and see if they can take being on the receiving end of health warnings.

To all you researchers, concerned health care workers, politicians, Uncle Tom Cobley and all who want us to do, or not do, physical things for our own good, I have only one thing to say to you: get a life!

Do you look at your own behaviour as well as everyone else's?

Do you regularly enjoy the company of friends and do things other than drink?

Do you get out and about, go for a walk or ride, watch a match or, better still, play one, rather than sit at home watching television or surfing the net?

Do you yourself create things or do you live off the creativity and enterprise of others?

Do you personally give something positive to society rather than take from it?

Do you know what it is to do something just for the fun of it, to let your hair down and say 'Whoopee!'?

Do you have a close personal relationship that you nurture every day? As you should know, this is by far the most important factor in health, even more significant than giving up cigarette smoking.

Life is for living, not for worrying.

There is much more to be gained than just another ten or twenty years of survival. Instead of getting people merely to live longer, we should encourage them to be spontaneous, creative and enthusiastic, to love and be loved. That's a life worth living even for just one more day.

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16 March 2012 6:07 PM

A married couple have been awarded $2.9m compensation against a hospital in Oregon, USA, for the failure of a pre-natal test to detect Downs' syndrome in their child. They say that they would have aborted the child if they had known the diagnosis.

My younger son's only child has had physical and mental challenges since birth. It is not for me to say what any couple should or should not do. Nor will I comment on the life that my son, his wife and their child have had. However, from my former work as a GP, I do know the enormous strain that any family experiences when there is a physically or mentally challenged child.

This news story worries me for another reason. Where will it lead?

In some communities, will girl foetuses be aborted for no reason other than their gender? Under the terms of The Abortion Act, that is illegal. But does it happen even now?

The opponents of the law said at the time that it would in due course lead to de facto abortion on demand. We may support this or oppose it but does it happen already to some extent?

Most abortions are carried out on the basis that the mental life of the mother would be damaged if the pregnancy were to continue. That is not difficult to argue.

Two independent doctors have to sign the form that makes the abortion legal. Their independence might be questionable at times but that possibility was predictable from the start.

Now we have a new factor. In this particular case in Oregon, the family claimed that a test was performed inaccurately. It appears that a sample was taken from the mother rather than the foetus. That seems to be a straightforward mistake, with severe implications when it comes to litigation.

But supposing, in the future, it comes to be expected that all tests should be 100% accurate and all babies 'perfect'. If everything does not work out as hoped, doctors and hospitals might be sued if any congenital abnormality is not detected prior to birth.

Further, it might be expected that any defect detected in a foetus should lead to an abortion, if the parents demand it.

One way or another, the law of the country and the expectations of some families are taking precedence over the personal beliefs and principles of doctors. When doctors become merely an instrument of the State, or of the demands of individual patients, that in itself is a very dangerous precedent.

The new case, even though it occured in America, is an even more dangerous precedent for all gynaecologists and hospitals.

As pre-natal diagnosis becomes progressively more accurate, another clause in The Abortion Act may come to be the most frequent cause of abortions: concern for the health of the child.

If Downs' syndrome is sufficient justification today, how about other physical or mental problems, that may come to be detectable pre-natally, tomorrow? There is a long list of medical conditions that require lifelong care at some level. They present a huge challenge to parents and other carers. Yet many are happy to take on that responsibility.

Subsequently they often describe the richness that these children bring to their lives.

There is an even longer list of conditions that might be seen as 'wrong' in those seeking perfection in their offspring. At what point will the law draw the line? Or are we approaching the time when abortion on demand is not only permitted but even, by some people, expected for any clinical condition that differs from the norm? Eugenics has an ugly history.

Like other doctors, perhaps especially in the private sector, I have been on the receiving end of expectations, or even demands, by individuals that I should say or write or do things that I do not believe in. I have also been on the receiving end of expectations by the State that I should do things that I do not believe in, such as drug substitution in the treatment of addiction.

My concern for the future is that fear of litigation will lead to the subservience of doctors and ultimately to totalitarianism.

On the present issue, let us suppose that, at some time in the future, there is a doubt over the interpretation of a pre-natal test result. Might the doctor or hospital err on the side of personal and financial caution and recommend an abortion rather than risk being sued?

What sort of doctors is our society creating? History has shown that doctors who do not think and act for themselves are a very dangerous breed indeed.

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15 March 2012 2:56 PM

Professor Sarah Harper, director of Oxford University's institute of population ageing, says that the country's love affair with medicine means that we choose to pop pills rather than follow a healthy lifestyle.I remember being taught to discourage the concept that we should take or prescribe a pill for every ill. Professor Harper takes this one step further by saying that we should beware of relying upon pills to keep us and our patients well.Bravely, she challenges the belief that statins are the holy grail. My prediction is that she will get absolutely nowhere. Patients want pills and doctors want to prescribe them. The pharmaceutical industry fulfils a perceived need, as well as trying to create one.We have an ambivalent relationship with Big Pharma. We like the miraculous clinical advances and we gladly take advantage of them. But we are concerned that doctors prescribe too much. We buy non-prescription medicines at every opportunity but we say that it is wrong for people to be so dependent upon them. We fear for our future health but we do little to promote it. As Professor Harper says, we prefer to pop pills.There is a simple reason for this: neither doctors nor patients want, or sometimes even know, what else to do.Doctors are trained to prescribe. So we should be. But we are rarely trained to do anything else. I had not one lesson on human psychology in my six years of undergraduate training. For almost all my training in non-medicinal therapies, I went to the USA. Yet, in my clinical practice, I was very much an orthodox doctor. There was nothing 'alternative' about me. I prescribed simple antibiotics and painkillers when they were really necessary. I very rarely prescribed sleeping tablets, tranquillizers or antidepressants. Analysis of my prescribing costs showed that they were only 40% of those of other GPs in my area of London. I do not believe that I looked after a group of patients who were particularly well. I had 3,500 NHS patients so I saw the same conditions that other doctors saw. I simply did not use medicines as my first clinical approach. I think that my patients were healthier as a result. Such dependencies as they may have had, did not come from me.Equally, I was unimpressed that statins were the answer to every medical problem. I am familiar with their benefits but I am also familiar, alongside Professor Harper, with the benefits of a healthy lifestyle.I myself do not take statins or aspirin or vitamins or anything other than the drugs that are specifically indicated for whatever I may have at any particular time. I do all sorts of things that keep me happy, active and creative. In particular, I am very familiar with the health benefits of a close personal relationship. That cannot be prescribed. Nor does it just happen. It has to be worked for.And this is where our entire 'something for nothing' culture falls down. Figures for national expenditure on prescription drugs, over-the-counter drugs and benefits of one kind or another, show that we have created a dependent population. But are we healthier and happier? That is the challenge that Professor Harper puts to us. If we are reluctant to take responsibility for ourselves, if we are physically and mentally able to do so, we run the risk of being hooked on the largesse of the government, the common sense and concern of doctors, and the benign efficacy of pharmaceutical products. I don't want that for myself or for people who ask for my help. I don't trust it.

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14 March 2012 11:35 AM

Researchers in Cambridge have found that laboratory rats, given the beta blocker drug Propranalol, have fewer cravings. Therefore they suggest that this drug could cure alcoholism in humans.

The researchers found that Propranolol could erase a stimulus in an animal's brain. They are now hoping that it can prevent 'cue-drug memory' in humans, when recollections of people or places or events associated with alcohol lead to a subconscious impulse to drink. They hope that the drug will strip emotion from the memory.

Propranolol has been around for years. It is used to calm the heart and calm the mind. In moderate or high doses it lowers the blood pressure. In low doses it reduces anxiety. It is used by vast numbers of people. Some of them will have been alcoholic. By now they would have reported any effect it had on reducing cravings. But they haven't.

It would not be difficult to do a simple search of medical records to see if it has worked already in reducing cravings. More complex research looks to me to be unnecessary and, perhaps, more related to marketing than to clinical care.

But there is a more serious flaw in this research. Rats are not humans. Our capacity to experience our feelings is much more developed than in animals. In many ways it is precisely what makes us human.

Also, just imagine that Propranolol does strip emotion away from memory. What a terrible thing that would be in a drug that is so widely prescribed. Again, would that not have been noticed already?

And imagine a life that does have emotion stripped away from memory. Last night I heard The Brodsky Quartet playing in The Wigmore Hall. Their music was inspiring, beautiful, wonderful. I remember the experience very well. Without the associated feelings, it would have been merely an interesting collection of notes.

Today I see that Arsenal are catching up Spurs in The Premiership. This threatens my belief in what life is all about.

Is an emotionless life what these researchers want for us? Heaven forbid.

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DR ROBERT LEFEVER

Dr Robert Lefever established the very first addiction treatment centre in the UK that offered rehabilitation to eating disorder patients, as well as to those with alcohol or drug problems. He was also the first to treat compulsive gambling, nicotine addiction and workaholism.
He identified 'Compulsive Helping', when people do too much for others and too little for themselves, as an addictive behaviour and he pioneered its treatment.
He has worked with over 5,000 addicts and their families in the last 25 years and, until recently, ran a busy private medical practice in South Kensington.
He has written twenty six books on various aspects of depressive illness and addictive behaviour.
He now provides intensive private one-to-one care for individuals and their families.

He has written twenty six books on various aspects of depressive illness and addictive behaviour.

He now uses his considerable experience to provide intensive private one-to-one care for individuals and their families.